Medical management of allergic eye disease

Treatment selection considers pathogenesis and disease severity

Cheryl Guttman Krader

Posted: Wednesday, March 7, 2018

Multiple pharmacological treatments are available for the medical management of allergic eye disease. Speaking at the 8th EuCornea Congress in Lisbon, Portugal, Mario Nubile MD outlined the appropriate use of these agents.

As a general principle, he told attendees to always keep in mind the mechanism of the allergy and the seriousness of the disease. Whereas seasonal allergic conjunctivitis and perennial allergic conjunctivitis are immunoglobulin E (IgE)-mediated conditions, IgE and non-IgE mechanisms are involved in the pathogenesis of vernal keratoconjunctivitis and atopic keratoconjunctivitis. The latter are also more severe, persistent conditions that can be sight-threatening.

“A dual-acting antihistamine/mast cell stabiliser should be the first choice for medical treatment of seasonal and perennial allergic conjunctivitis. These agents also have an effect on inflammation that is a feature of all allergic eye diseases. Corticosteroids, however, are rarely needed in these cases,” said Dr Nubile, Head, Cornea and Ocular Surface Service, Regional Centre of Excellence in Ophthalmology, University G D’Annuzio, Chieti-Pescara, Italy.

“A dual-acting agent should also be used as front-line therapy for atopic and vernal keratoconjunctivitis, but topical corticosteroids are also indicated for these conditions, especially when the cornea is involved.”

Dr Nubile recommended starting with a “soft” corticosteroid (loteprednol or fluorometholone) whenever possible, but said a more potent agent (prednisolone or dexamethasone) may be needed, especially to mitigate the risk of scarring in eyes with corneal lesions.

Corticosteroids should be given as short, pulsed therapy, tapered to the lowest effective dose, and used with careful monitoring for safety. As an alternative to topical treatment, corticosteroids can be administered as a supratarsal injection in very severe cases, he said.

Evidence also supports treatment of atopic and vernal keratoconjunctivitis with topical calcineurin inhibitors (TCIs; cyclosporine, tacrolimus), which are less powerful than corticosteroids, but safer. Use of the TCIs for treating atopic and vernal keratoconjunctivitis, however, is off-label in the European Union, and therefore they may be best prescribed by physicians in specialised centres, Dr Nubile said.

Cyclosporine is the more accessible agent of the two TCIs, and there are more published data describing its use for treatment of ocular allergy. While there is no consensus on the minimum effective concentration for cyclosporine, Dr Nubile suggested that at least 1% to 2% may be needed.

He recommended that systemic anti-allergy therapy, including oral antihistamines, oral omalizumab, and allergen-specific sublingual immunotherapy, should only be used when patients have other allergic comorbidities, such as asthma or rhinitis.